Vaccination Volunteer Questionaire

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* 1. Name

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* 2. Address

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* 3. Phone Number

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* 4. Email Address

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* 5. Please mark the areas that you would like to volunteer for (mark all that apply)

Door Greeter

Assist with client temperature checks upon client arrival

Assist with client check-in

Assist clients with completing forms

Assist with traffic flow within the clinic stations

Assist with traffic flow outside the clinic

Observe clients after their injection and alert nursing staff of any concerns

Provide and explain printed handouts to clients

Assist with cleaning surfaces between clients

Administer vaccines (Please only check this box if you are a RN or LPN with an active and unencumbered Missouri license

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* 6. If you are a qualifying RN or LPN and you would like to volunteer to administer vaccinations, please answer the following question (all other survey participants, please mark N/A)

N/A

I have an active and unencumbered RN license in the State of Missouri and I have included my license number below

I have an active and unencumbered LPN license in the State of Missouri and I have included my license number below

License Number

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* 7. If you are a qualifying RN or LPN and you would like to volunteer to administer vaccinations, please answer the following question (all other survey participants, please mark N/A)

N/A

Do you carry nursing liability insurance? If so, who is your insurance through? Are you willing to provide the health department administrator with your insurance policy information?

Insurance Carrier

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* 8. If you are a qualifying RN or LPN and you would like to volunteer to administer vaccinations, please answer the following question (all other survey participants, please mark N/A)

N/A

I have a current CPR certification and I am willing to provide a copy of my certification to Christian County Health Department

My CPR certification is expired, but I anticipate renewing my CPR (please put date below)

CPR Expiration Date

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* 9. If you are a qualifying RN or LPN and you would like to volunteer to administer vaccinations, please answer the following question (all other survey participants, please mark N/A)

N/A

I have already completed the three required vaccination training modules listed within the link below and I am willing to provide my training certificates to Christian County Health Department. Training link: https://www2.cdc.gov/vaccines/ed/covid19/index.asp

I have not completed the three required training modules at the link provided below, but I am willing to complete the training modules and provide my training certificates to Christian County Health Department upon completion. Training link: https://www2.cdc.gov/vaccines/ed/covid19/index.asp

Date of anticipated completion or date completed

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* 10. What days of the week are you available to volunteer (Please mark all the apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday